VOLUNTEER APPLICATION 238 Merrimac Court, PO Box 838 Prince Frederick, MD 20678

Thank you for your interest in becoming a volunteer with Calvert Hospice. This application has been developed specifically for our program. You may find that some of the questions are personal in nature, but we have found this information helpful in making volunteer selections and assignments. All information provided is confidential.

FIRST NAME: LAST NAME:

EMAIL: HOME PHONE:

CELL PHONE:

STREET ADDRESS:

CITY:

STATE: ZIP:

EMPLOYMENT HISTORYCOMPANY ADDRESS

POSITION DATES

COMPANY ADDRESS

POSITION DATES

MILITARY HISTORYBRANCH DATES

VOLUNTEER HISTORYORGANIZATION VOLUNTEER

POSITION

ORGANIZATION VOLUNTEER POSITION

ORGANIZATION VOLUNTEER POSITION

RELEVANTBACKGROUND (MAY INCLUDE

EDUCATION, COMMUNITY SVC, FAMILY

EXPERIENCE)

Why do you wish to become a

hospice volunteer?

Do you have health / physical

problems that limit your ability to

perform required tasks? Please

explain.

BEREAVEMENT HISTORYDECEASED'S

NAMEDATE OF

DEATH

HOSPICE PATIENT?

YES OR NO

DECEASED'S AGE AT DEATH

CAUSE OF DEATH

RELATIONSHIP

DECEASED'S NAME

DATE OF DEATH

HOSPICE PATIENT?

YES OR NO

DECEASED'S AGE AT DEATH

CAUSE OF DEATH

RELATIONSHIP

ARE YOUBILINGUAL?

YES

NO

WHAT LANGUAGE?

DO YOU POSSESS A VALID DRIVER'S

LICENSE?

YES

NO

DRIVER'S LICENSE NUMBER & STATE

DO YOU HAVE ACCESS TO A CAR?

YES

NO

AUTO INSURANCE CO. & POLICY

NUMBER

TIMES YOU'RE AVAILABLE FOR

VOLUNTEER WORK

DAYSWEEKENDSEVENINGS

HAVE YOU EVER BEEN CONVICTED

OF A CRIME?

YESNO

HAVE YOUEVER HAD

YOUR LICENSE REVOKED?

YESNO

ARE YOU CURRENTLY UNDER INVESTIGATION OR PENDING

CHARGES?

YESNO

Please share the names and contact information of three people we can contact for a personal reference.

NAME: PHONE OR EMAIL:

NAME: PHONE OR EMAIL:

NAME: PHONE OR EMAIL:

____ I understand that Calvert Hospice recruits volunteers and employees, and provides care to patients without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. _____ I understand that Calvert Hospice's drug and alcohol policy prohibits the use of alcohol or illegal drugs while working or volunteering.

SIGNATURE DATE